Alzheimer

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The Role of Psychosocial Intervention in the Treatment of Alzheimers Disease

Mary S. Mittelman, Dr.PH
Director, Psychosocial Research and Support Program William and Sylvia Silberstein Institute for Aging and Dementia Research Associate Professor, Department of Psychiatry New York University School of Medicine New York, New York
Why Will Treating the Caregiver Help the Patient? n As the patients dementia becomes more severe,
family members play an increasingly important part in their care
n
Family caregivers are at risk of depression

n
Lack of sufficient support has been linked to depression in caregivers Troublesome patient behavior has been linked to depression in caregivers
n n
Caregiver depression may affect patient care Counseling and support for the caregiver can help keep patients from premature institutionalization
The NYU Caregiver Intervention Study

A Randomized Controlled Trial to Test the Efficacy of Counseling and Support for Spouse Caregivers
Design of the NYU Intervention Study

n n
n n
Comprehensive baseline interview Random assignment to the treatment or control groups Regular comprehensive follow-up interviews All participating caregivers receive the services routinely available at the NYU-ADC
Goals of Intervention
n n
To help the caregiver survive the illness To postpone or prevent nursing home placement of the person with AD
Study Subjects
406 spouse-caregivers of people with Alzheimers disease Enrollment began in 1987 Enrollment ended in 1997
n n
Components of the Intervention
n n n n
Scheduled individual counseling sessions Scheduled family counseling sessions Support group participation Unlimited consultation on request (ad hoc counseling)
Treatment Given to All Study Subjects

n n n n
Regular follow-up interviews. Resource information on request. Help in an emergency. Routine services normally provided to patients and family members .
Differences Between the Treatment and Control Groups

n
Who receives formal counseling

n
Caregivers and families in the treatment group No one in the control group. Caregivers and families in the treatment group Caregivers in the control group.
Who the counselors know

n
Psychosocial Intervention Improves Caregiver Satisfaction With Social Network

6
N = 206
Level of satisfaction
5 4 3 2 1 0 0 4 8 12
Control group Treatment group
Months from baseline

Mittelman MS, et al. In: Heston LL, ed. Progress in Alzheimers Disease and Similar Conditions. Washington, DC: American Psychiatric Publishing; 1997:259.
Psychosocial Intervention Has No Effect on Frequency of Problem Patient Behavior

1.78 1.76 1.74 1.72 1.70 1.68 1.66 1.64 1.62 1.60 1.58 1.56 0 0
N = 406
Frequency (log base 10)
12
24
36
Months from intake

Mittelman MS. Presented at: 8th International Conference on Alzheimers Disease and Related Disorders; July 20, 2002; Stockholm, Sweden.
Psychosocial Intervention Improves Caregiver Reaction to Patient Behavior

1.40
N = 406
Reaction (log base 10)
1.38 1.36 1.34 1.32 1.30 1.28 1.26 0 0 12 24 36

Months from intake

Psychosocial Intervention Reduces Caregiver Symptoms of Depression

15
N = 206
Number of symptoms
12 9 6 3 0 0 4 8 12
Months from baseline

Mittelman MS, et al. Gerontologist. 1995;35:792.
Effect of Psychosocial Intervention on Symptoms of Caregiver Depression Continues Over Time Depression (Years 1-5)
11
N = 406
Number of symptoms
10
Usual care Treatment
7 52 104 156 208 260
Weeks
Caregivers Are Able to Keep their Spouses with AD at Home Longer

1.00
N = 206
Cumulative survival
0.75
Treatment group Control group
0.50
0.25
0 0 1 2 3 4 5 6 7 8
Years from baseline

Mittelman MS, et al. JAMA. 1996;276:1725. Mittelman MS. Presented at: 8th International Conference on Alzheimers Disease and Related Disorders; July 20, 2002; Stockholm, Sweden.
Conclusions
A long-term program of family counseling and support n Prevents increasing caregiver depression n Reduces severity of caregiver reaction to patient behavior n Helps spouse caregivers keep patients at home
The NYU-ADC Caregiver Core
Mary Mittelman, Dr.P.H. Core Leader Gertrude Steinberg, M.S. Emma Shulman, C.S.W. Cynthia Epstein, A.C.S.W. Alicia Pierzchala, C.S.W
Research Facilitated by the Caregiver Core

n
3 Country Study
n
Counseling for caregivers + Aricept for patients vs Aricept for patients Improving care for patients and family members Workshops, written material and counseling
Acute hospitalization
n
New intervention for adult child caregivers

n
Research Facilitated by the Caregiver Core

n
Development of an intervention for people with MCI

n
Individual and group interviews with patients and spouses Memory training and support
Minority supplement to Spouse Caregiver Intervention Study

n
Perceptions of early symptoms of MCI and AD among Latino and non Latino caregivers
The 3 Country Study
New York, USA Randwick, Australia Manchester, England
Goals of the 3 Country Study
To answer two questions:

Does psychosocial support for the family caregiver have benefits over and above the effects of drug treatment for Alzheimer's disease? n Is the effect of psychosocial support the same in all 3 countries?
n
Design of 3-Country Study

n n n
Single-blind, prospective randomized trial Primary caregiver is patients spouse 150 patient/caregiver pairs (50 in each country) 2 groups of subjects in each country
Drug treatment for patient + psychosocial intervention for caregiver n Drug treatment for patient
n
Treatment Given to All Study Subjects

n
n n n n
All participating patients received Aricept at no cost. Regular follow-up interviews. Resource information on request. Help in an emergency. Routine services normally provided to patients and family members at each site.
Psychosocial Intervention has a Significant Effect on Caregiver Depression

2 1
Change in Beck Depression Score
0 -1 -2 -3 -4 -5 -6 -7 0 3 6 9 12 18 24
Treatment Control
Months from Baseline
Time to Dropping Out of the Study was Different in the 3 Countries
Probability of Nursing Home Placement was Different in the 3 Countries
Conclusions
n
Counseling and support can alleviate symptoms of depression in caregivers Medical and social care policies affect outcomes of psychosocial intervention Caregivers in the 3 countries responded differently to intervention. The challenge will be to explain why. Psychosocial intervention, in combination with pharmacologic intervention, can be of substantial value to caregiver and patient.
Psychosocial Interventions for Individuals with MCI

Funded by Fan Fox Foundation
A Pilot Study of Psychosocial Interventions for Individuals with MCI n Phase I

n n n
Individual interviews Group discussions Find out what kind of help people with MCI wanted Pilot study of intervention requested by subjects in Phase 1
Phase II
n
Results of Phase I
n
In individual interviews, most people with MCI in this study felt their memory impairment was no worse than other people their age. Subjects were more able to admit to memory problems in a group setting with others like themselves than in individual interviews. Subjects wanted memory training in groups, but not support groups.
Results of Phase II
n
A significant increase in ability to recognize faces, as evidenced by performance on the Face Recognition subtest of the Wechsler Memory Scale Subjects in combined intervention had no difference in results compared to those in memory enhancement classes.
Improving Care for Patients and Family Members
An Innovative Psychosocial Intervention for Adult-Child Caregivers of Parents with Alzheimers Disease
Funded by the Langeloth Foundation July 2003
Goals
n
Goal of Intervention
n
To reduce negative effects of caregiving - stress, anxiety, and depression To compare a written intervention coupled with ad hoc counseling to a more intensive intervention that includes personal and group counseling as well.
Goal of Study
n
Basis for Intervention

n
There are no interventions designed specifically for adult child caregivers The middle stages of AD are extremely difficult for caregivers A pilot study funded by Fan Fox Foundation had promising results.
Design of Study
n n n n
Randomized control design Two levels of intervention Two follow-up interviews Subjects
100 adult child caregivers n Parents in middle stages of AD
n
Intervention
n
Control group
Workbook especially prepared for this study n Ad hoc counseling
n
Treatment group
Two workshops n One individual counseling session n Workbook especially prepared for this study n Ad hoc counseling
n
Summary
n
Psychosocial interventions are an essential element in patient care. Research is needed to develop new and improved interventions Please participate in our studies to help yourselves and others.

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Generated by Foxit PDF Creator Foxit Software http://www.foxitsoftware.com For evaluation only.

The Role of Psychosocial Intervention in the Treatment of Alzheimers Disease

Family caregivers are at risk of depression

The NYU Caregiver Intervention Study

Design of the NYU Intervention Study

Components of the Intervention

Treatment Given to All Study Subjects

Differences Between the Treatment and Control Groups

Who receives formal counseling

Who the counselors know

Psychosocial Intervention Improves Caregiver Satisfaction With Social Network

Months from baseline

Psychosocial Intervention Has No Effect on Frequency of Problem Patient Behavior

Frequency (log base 10)

Control group Treatment group

Months from intake

Psychosocial Intervention Improves Caregiver Reaction to Patient Behavior

Reaction (log base 10)

1.38 1.36 1.34 1.32 1.30 1.28 1.26 0 0 12 24 36

Months from intake

Psychosocial Intervention Reduces Caregiver Symptoms of Depression

Months from baseline

Usual care Treatment

7 52 104 156 208 260

Caregivers Are Able to Keep their Spouses with AD at Home Longer

Treatment group Control group

Years from baseline

The NYU-ADC Caregiver Core

Research Facilitated by the Caregiver Core

New intervention for adult child caregivers

Research Facilitated by the Caregiver Core

Development of an intervention for people with MCI

Minority supplement to Spouse Caregiver Intervention Study

The 3 Country Study

New York, USA Randwick, Australia Manchester, England

Goals of the 3 Country Study

To answer two questions:

Design of 3-Country Study

Treatment Given to All Study Subjects

Psychosocial Intervention has a Significant Effect on Caregiver Depression

Change in Beck Depression Score

Months from Baseline

Time to Dropping Out of the Study was Different in the 3 Countries

Probability of Nursing Home Placement was Different in the 3 Countries

Psychosocial Interventions for Individuals with MCI

A Pilot Study of Psychosocial Interventions for Individuals with MCI n Phase I

Improving Care for Patients and Family Members

Basis for Intervention

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